Original Research Article

Modifications and innovations in mc indoe vaginoplasty for better outcomes

Chanjiv Singh Mehta1*, Gursehaj Mehta2

1HOD, 2Post Graduate, Dept. of Surgery, 1Civil Hospital, Jalandhar, Punjab, India 2ISM Bishkek, Kyrgyzstan

*Corresponding Author: Chanjiv Singh Mehta Email: [email protected]

Abstract Vaginal agenesis is one of the most common female genital disorders. It may be an isolated problem or part of a syndrome. Apart from congenital causes, there are many other indications for vaginal reconstruction. Diagnosed late and having complex psychological issues, the reconstruction to provide a normal functioning is a challenge. Although numerous techniques are described, there appears to be no consensus on which is the ideal one. Nor is there one opinion on when the reconstruction should be taken up. The McIndoe technique 22,26,27, has been used over the ages with success. Many modifications 43,45 have been described. The present paper describes some modifications with which better results can be achieved consistently with this technique.

Keywords: Vagina and neovagina, Vaginoplasty, Agenesis, Syndrome, MRKH, McIndoe, condom, Foam, Amniotic membrane, Paraffin gauze, Negative pressure.

Introduction Patients with vaginal agenesis are often diagnosed Vaginal agenesis is one of the most psychologically late if antenatal scans don’t pick it (Transvaginal scans traumatic congenital anomalies of the female are not done routinely in ). The pediatricians reproductive tract. As a newborn or child cannot or Obstetricians miss it at , then they usually understand it, the mental trauma is borne by the parents. present with primary amenorrhea, failure of The incidence is estimated at 1 in 4,000-5,000 live consummation of marriage or with . Left female births. Vaginal agenesis occurs either as an untreated, vaginal agenesis can result in devastating isolated developmental defect or within a complex of repercussions on fertility, sexual function and more extensive anomalies, most commonly associated psychology. Inadequate correction can result in a major with Mayer-Rokitansky-Küster-Hauser syndrome liability. (Mullerian agenesis) 20,24,38,. MRKH is described as Creating a functional neo vagina is a challenge, the congenital vaginal agenesis in an individual with aim being to provide a vagina of an appropriate length, normal female genotype, phenotype and normal adequate caliber and with aesthetic acceptance10. There endocrine status. Type I MRKH syndrome 50,53 is are several non surgical and surgical techniques characterized by an isolated absence of the proximal described in literature 1,2,7,11,12,13. The very fact that two-thirds of the vagina, whereas Type II is marked by there are so many described techniques attests to the other malformations- vertebral, cardiac, urologic and fact that no single technique is the perfect answer to this ontological anomalies: Renal (34%) and the skeletal complex problem. (12%). The ovarian function in these patients is usually The timing of surgery depends on the patient's normal. anatomic configuration and on the presence or absence Apart from patients of vaginal agenesis, patients of functional endometrial tissue. Opinion varies as to with complete or partial androgen insensitivity, when this correction should be taken up. transsexuals and patients with acquired defects following trauma, resection of pelvic tumour or Aims and Objectives radiotherapy may present for treatment. Gender The author has undertaken different vaginal reassignment has come up as a modern fad. Apart from reconstructive procedures for over 29 years. The the physical issue, it is a major psychological problem. present series is the use of McIndoe technique, with IP International Journal of Aesthetic and Health Rejuvenation, July-September, 2020;3(3):60-67 60 Chanjiv Singh Mehta et al. Modifications and innovations in mc indoe vaginoplasty for better outcomes… some modifications 28,29,35. The aim of this article is they could be advanced into the neo vagina. Then a to present these adaptations and modifications to the vesico-rectal space was created by blunt dissection McIndoe Vaginoplasty 41,43,45 to simplify the between the , bladder and the reaching up procedure so that we can achieve consistently to the pouch of Douglas. The assistant kept her middle acceptable results. finger in the rectum guiding the dissection. The cavity was packed with roll gauze which was removed after 10 The important steps include mins to ensure haemostasis. The cavity was packed post 1. Creating an adequate space for the neo vagina. operatively with betadine lotion soaked roll gauze and 2. Decreasing the possibility of injury to the bladder patient was transferred to post op. Stage II was taken up and rectum. on the next day. A mould was created using a condom 3. Achieving haemostasis to ensure proper stuffed with betadine lotion soaked roll gauze (Fig.1). resurfacing. The amniotic membrane was harvested from a sero 4. Use of amnion to avoid donor site morbidity 54. negative donor undergoing C-section. It is cleaned and 5. Using a suitable and easily available mould post banked in normal saline. It was stitched over the operatively and ensuring the stability of graft when condom-mould covered with paraffin gauze. the mould is changed for dressing. The patient was placed in lithotomy again under 6. Providing sensation at the proximal part of the neo sedation. The pack is removed providing a dry space for vagina. the graft which ensures a good uptake. The condom mould with the graft is inserted. The edges of the Materials and Methods amniotic membrane graft 3,9,15,40,54 are stitched to This study has been undertaken in 11 cases of vaginal the X flap tips which drew the flaps in when dressing reconstructions from 2005 to 2012 with an average pressure was applied. A dressing pad was placed over it follow up of 5-8 years. All the cases selected were of and the labia are loosely stitched together using silk primary agenesis where no procedure had been tried sutures to retain it in place. A T-bandage was applied. earlier. None of these patients had functioning In three cases we used a 40 density foam splint rolled endometrial tissue or a normal . on itself and in one a splint cut out from a foam block All patients underwent routine investigations covered with a condom. including USG (KUB) to rule out major renal The patient was advised to keep her thighs in anomalies. The surgical team consisted of a plastic adduction. The was maintained for 1 surgeon and a gynecologist. Before starting the surgery week. All patients urinated smoothly and no fistulae for stage I, Inj. Amoxyclav 1.2 was administered as a were found. In one case where there was a doubt of prophylactic antibiotic on the night before and one hour bladder injury, catheterization was maintained for 14 before surgery. Local Hygiene and cleaning the perianal days. All the patients were placed on a liquid diet on the area with betascrub for 3 days prior to surgery was second day after stage II and a normal diet after a week. undertaken with liquid diet for the same duration with Antibiotic was given for a week post operatively. standard PEGLAC solution from 4 pm to 10 pm a day The mould was removed on the fourth day with before stage I surgery. thighs in abduction and by cutting the labial stitches, The surgery was done in two stages. softly pulling out the roll gauze followed by the condom Stage I: Creating a space for the neo vagina. and paraffin gauze. In cases where foam splint was Stage II: Insertion of mould with amniotic used, it was deflated with negative pressure to help in membrane graft. change/removal. The newly created vagina was For stage I all the patients were operated under irrigated with diluted (1%) povidone-iodine solution spinal anaesthesia in the lithotomy position with and normal saline. A new condom wrapped with urethral catheterization. An X-shaped incision is given paraffin gauze was placed and stuffed with roll gauze in the perineum at the dimple or existing depression. soaked in betadine lotion. After 4-5 days it was The lateral part of the X flaps were dissected so that removed and the neo vagina irrigated in the same IP International Journal of Aesthetic and Health Rejuvenation, July-September, 2020;3(3):60-67 61 Chanjiv Singh Mehta et al. Modifications and innovations in mc indoe vaginoplasty for better outcomes… manner. A prosthetic mould was placed in the neo vagina covered with a condom and the patient educated in its removal and reinsertion. A mould made from a candle or dental compound was given to the patient to use. The patients were allowed to engage in sexual intercourse after 3 months (if they were married or had a companion) after joint consulling of both the partners. The mould use was incrementally decreased over the Fig 1: Condom stuffed with roll gauze soaked in next 2-3 months until the patient kept the mould in the betadine lotion to use as a . new vaginal cavity for only a short time each day. Six months after the surgery, if the patient engaged in regular sexual intercourse, the frequency of the mould use was left to the patient.

Fig 2: Condom covering foam piece with negative pressure apparatus.

Table 1: Characteristics of patients who underwent modified McIndoe vaginoplasty Patient Age at surgery Other Operating Operating Hospitalisation Complications in years abnormalities time stage I time stage 2 in days 1 18 Nil 22 min 10 min 7 days 2 17 Nil 30 min 08 min 7 days 3 21 Nil 20 min 11 min 7 days 4 23 Nil 25 min 10 min 10 days Bleeding 5 17 Nil 22 min 10 min 7 days 6 18 Nil 25 min 12 min 7 days 7 17 Nil 28 min 08 min 14 days Suspected bladder injury 8 15 Nil 22 min 09 min 7 days 9 19 Nil 20 min 08 min 7 days 10 19 Nil 22 min 10 min 7 days 11 16 Nil 18 min 08 min 7 days

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Discussion The confirmation of the diagnosis is inevitably a psychological shock for the patient and her family. The absence of a vagina has a profound impact on the young woman’s sense of femininity. Aesthetically and functionally inadequate correction can result in major

psychological problems in adolocent age and even Fig 3: Condom contain foam piece collapsed with result in marital disputes. Counselling the parents and negative pressure making them a part of the treatment team helps in

promoting long term satisfaction. The treating surgeon must keep in mind to be practical and not give too many assurances to the patient and family. Vaginoplasty is considered as the major therapeutic strategy for these patients. The main reason for the creation of a neo vagina in is to make sexual intercourse possible for these patients. Ideally, the creation of a neo vagina should be simple, safe, and most importantly, should allow for satisfactory sexual intercourse. In some cases with a normal uterus it might even be possible to have a child. The McIndoe technique was first described in 1938

Fig 4: Foam piece and suction catheter kit by Bainster and McIndoe 6,8,16,18. Despite the existence of several alternative methods, there is still no consensus regarding the best option for surgical correction. As with the majority of surgical procedures, the first operation is likely to be the most successful17,25. In a fresh case it is relatively easy to create a proper space and maintain it post operatively with a cooperative patient. Decreasing the possibility of injury to the bladder by use of catheter and to the rectum by the assistant placing a finger in the rectum is very practical. There Fig 5: Form roll with catheter for negative pressure has been the use of rectal tube for this purpose but a finger is live and responsive and can actually guide the dissection. Staging of the procedure produces a satisfactory haemostasis which is essential for membrane uptake. We have found this extremely useful even in cases where we used STSG 5,19,44. We have never used cultured epidermal cells14 at our centre. Using a suitable and easily available mould gives satisfactory pressure and avoids the traction on the membrane during dressing change. The betadine lotion Fig 6: /stent soaked roll gauze mould gives the advantage of removal of the roll gauze and then the condom and paraffin gauze at the first dressing causing no traction on the IP International Journal of Aesthetic and Health Rejuvenation, July-September, 2020;3(3):60-67 63 Chanjiv Singh Mehta et al. Modifications and innovations in mc indoe vaginoplasty for better outcomes… amnion. In four cases we used a condom filled with intervention. Deferring the treatment allows the woman foam and collapsed it with negative pressure (Fig 2). herself to be involved in the decision making but also After insertion the negative pressure was released so increases compliance with adjuvant dilation therapy. that the foam swelled up to provide pressure in the neo Immediate complications generally are vagina (Fig 3). The removal was done with again haemorrhage and haematoma formation. These were applying negative pressure to collapse the mould. The avoided by the two stage technique. The packing use of a condom mould post operatively and using a provides a natural method of producing haemostasis condom to cover the stents during follow up provide a without any cautery. Pain and scarring and hypertrophy cheap and readily available method of ensuring hygiene at the donor site seen if STSG44 is used was avoided by and prevent infection. The results with use of condom uses of amnion. Careful dissection prevents bladder or packed with betadine gauze and foam were comparable. rectal injury. The use of the assistants finger in the The insertion of the dissected flaps prevents rectum is live and responsive in the dissection. stenosis and provides sensation at the proximal part of The malodorous mucoid discharge seen with the the neo vagina17,25,33. We have been using STSG sigmoid or intestinal reconstruction is not seen with this 5,19 as well as buccal mucosa prior to this series but technique. Complications like prolonged non-infective prefer amnion as there is no donor site morbidity. The discharge, recto vaginal , vesico vaginal fistula, donor scars in asian skin are likely to undergo failure of membrane uptake were not seen in this study. hypertrophy. In cases where we did use STSG 44 No serious occurred during the peri or earlier, the graft was taken from the posterior surface of post operative period. Many cases with STSG have had the thigh so that the patients could not easily see the incidence of Squamours cell carcinoma 4,23,46 which donor site. have not been seen with amniotic membrane. We have no experience with the use of tissue- We have not undertaken any studies to evaluate the engineered biological mesh. Adjuvant therapy such as functional sexual outcomes after the creation of a neo post operative vaginal dilation treatment and vagina by this or other surgical techniques. We plan to psychological support can influence outcome and start assessing the sexual functional results using satisfaction of the patient. a FSFI (female sexual function index) standardized The ideal time for intervention is after adolescence, questionnaire. when the woman has reached physical and There are limitations in our study. First is the psychological maturity. In the past, vaginal relatively small sample size and the other is the absence reconstruction procedures using pudendal and gracilis of a control group. However, all the included cases are flaps 36,37,42 were performed on infants and pre consecutively and contemporarily collected. Second no pubertal girls in our centre. The concept was that a child study was done about the flora of the neo vaginal with a normal uterus could be spared the trauma of microecology after vaginoplasty. Thirdly no histo discovering her deformity on attaining puberty. But pathological samples were taken from the neo vagina surgical revisions were almost always needed in for analysis. adolescence thus defeating the purpose of this early

Table 2: Advantages and disadvantages of this technique. Advantages Disadvantages Does not require abdominal surgical entry Vaginal dryness Use of amnion prevents donor site morbidity Post operative dilation or sexual intercourse is required No risk of hypertrophic scarring Potential risk of disease transmission No change in vaginal flora Stricture formation Quicker and complete procedure than dilatation Use of STSG can produce hair in the neo vagina There is less emotional stress There is a reported risk of squamous cell carcinoma

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vaginal agenesis, but proper mould usage after surgery Results remains the cornerstone of the treatment. Further A successful surgical intervention is creating a new research is needed to prospectively evaluate the clinical vagina with adequate length that is functional and success of different surgical techniques. sensitive, but not limited only to the length and dimensions. Therefore, successful metaplasia in the Source of Funding membrane also plays an important role in the sensitivity None. and elasticity of the newly created vagina. The final results were excellent in all the cases with complete Conflict of Interest graft take, satisfactory dimensions of the neovagina and None. no stenosis or . One patient however had minimal bleeding during mould insertion after 2 weeks References which subsided with the conservative management. All 1. Abbe R. New method of creating a vagina in case of the patients came for regular follow-up except one. All congenital absence. Med Rec (NY). 1898;54:836-8. patients who underwent this surgery were compliant 2. ACOG Committee Opinion Nonsurgical diagnosis and management of vaginal agenesis. Obstet with postoperative vaginal mould use. Gynecol 2002;100:213-6. The psychological outcome was also very 3. Ashworth MF, Morton KE, Dewhurst J, Lilford RJ. and encouraging. Consuling was also provided to the Bates RG. Vaginoplasty using amnion. Obstet. husbands/partners of these patients. For the unmarried Gynecol., 1986;67:443–6. 4. Baltzer J, Zander J. Primary squamous cell carcinoma of patients, the mothers were consuled. Most of the the neovagina. Gynecol Oncol 1989;35:99-103. patients who came for follow-up after the marriage 5. Banister JB, McIndoe AH. Congenital Absence of the reported satisfactory sexual relationships and were Vagina, treated by Means of an Indwelling Skin- satisfied with the vaginal depth. Graft. Proc Royal Soc Med. 1938;31:1055–6. 6. Bastu E, Akhan SE, Mutlu MF, Nehir A, Yumru H, Hocaoglu E, et al. Treatment of vaginal agenesis using a Conclusion modified Mc Indoe’s Technique-long tern follow up of 23 Vaginal agenesis is complex situation and making a patients and literature review. Can J Plast Surg. surgical decision making is a highly testing matter. As 2012;20(4):241-4. surgical skills and technologies become more advanced, 7. Bhathena HM. The vacuum expandable condom mold for reconstruction of vagina. Plast Reconstr Surg. surgeons are extending them to neo vaginal 2006;115:973. construction. Laparoscopic techniques do have a small 8. Buss JG, Lee RA. Mcindoe procedure for vaginal agenesis: role in treating women who have failed vaginal dilation results and complications. Mayo Clin Proc 1989; or attemped surgery. Newer techniques using 64(7):758-61. autologous vaginal tissue may in the future increase the 9. Chohan A, Burr F, Mansoor H, Falak T. Amnion graft in vaginoplasty- an exprtience at 3 teaching hospitals of armamentarium available to clinicians dealing with Lahore. Biomedica. 2006;22(1):21-4. these rare conditions. These women should be only 10. Chudacoff R.M, Alexander J, Alvero R. and Segars J.H. managed in specialist centres by a multidisciplinary Tissue expansion vaginoplasty for treatment of congenital team with psychological support. Specialist units vaginal agenesis. Obstet Gynecol. 1996:87:865–8. 11. Capraro, V.J and Gallego, M.B. Vaginal agenesis. Am J should be able to offer all treatment options and also Obstet Gynecol. 1976;124:98–07 have a duty to provide long‐term outcome data. 12. Davies MC, Creighton SM. Vaginoplasty. Curr Opin Urol. To optimize sexual comfort, the clinical management of 2007;17:415–8. women with vaginal agenesis must be multidisciplinary 13. Davies MC, Creighton SM, Woodhouse CRJ. The pitfalls of vaginal construction. BJU Int 2005;95:1293-8. and individually tailored. Our 14. Dessy LA, Mazzocchi M, Corrias F, Ceccarelli S, Marchese C, Scuderi N. The use of cultured autologous oral epithelial cells for vaginoplasty in maleto-female findings suggest that the modified McIndoe technique transsexuals: a feasibility, safety, and advantageousness is a simple, effective procedure for the treatment of clinical pilot study. Plast Reconstr Surg. 2014;133:158–61. IP International Journal of Aesthetic and Health Rejuvenation, July-September, 2020;3(3):60-67 65 Chanjiv Singh Mehta et al. Modifications and innovations in mc indoe vaginoplasty for better outcomes…

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